Comparison of two survey methods for estimating unplanned pregnancy, Bangladesh

Abstract Objective To compare the prevalence of unintended pregnancy measured by the Demographic and Health Survey (DHS) and the London Measure of Unplanned Pregnancy in Bangladesh, and explore the extent of discordance between the measures and the factors associated with the discordance. Methods In 2023, we conducted a cross-sectional survey in four randomly selected districts in Bangladesh: Kurigram, Mymensingh, Pabna and Satkhira. We randomly selected 20 hospitals, five from each district. We collected data from 1200 women who had recently delivered a baby and were visiting the hospitals for postnatal care. We interviewed the women about their pregnancy intention in their last pregnancy using questions in the DHS and the London Measure of Unplanned Pregnancy and examined the discordance in their responses. We used multivariable logistic regression analysis to identify factors associated with discordant responses in reported pregnancy intention. Findings The prevalence of unintended pregnancy was 24.3% (292/1200) using the DHS measure and 31.0% (373/1200) using the London Measure of Unplanned Pregnancy. Discordance in responses to pregnancy intention between the two measures was 27.1% (325/1200). Factors associated with discordance were older age, female sex of the last child born, having more than two children, being in a poorer wealth quintile, living in a rural area and living in Kurigram district. Conclusion The prevalence of unintended pregnancy in Bangladesh measured by the DHS measure may be an underestimate, suggesting that the adverse effects of unintended pregnancy are greater than realized and emphasizing the need to bolster Bangladesh’s family planning programme.


Introduction
Globally, about half of pregnancies (roughly 121 million) are unintended, with low-and middle-income countries bearing the brunt due to lower use of modern contraception and higher unmet contraceptive needs. 1,2In Bangladesh, unintended pregnancy is an important issue.In one study, 25.2% (1131/4493) of women with live births reported that the pregnancy was unintended. 3Unintended pregnancies can have substantial adverse effects on maternal and child health, especially in lowand middle-income countries such as Bangladesh, where safe abortion services are limited by law. 1,4Around two thirds of unintended pregnancies in low-and middle-income countries and Bangladesh result in induced abortions.These abortions account for an estimated 13.0% of total maternal deaths and incur substantial costs for treating abortion-related complications. 1,5][10] Increasing access to modern contraception and comprehensive sex education is vital to reduce unintended pregnancies in Bangladesh. 3 The accuracy of current estimates of unintended pregnancy is a global concern, particularly in low-and middle-income countries where prospective data on reproductive events (e.g.conception and birth) are scarce, and data on unintended pregnancy usually come from nationally representative De-mographic and Health Surveys (DHS). 5These surveys collect timing-based data on pregnancy intention using two questions.These questions have several limitations, including recall bias, particularly in accurately remembering pregnancy intentions at conception, and a higher likelihood of ambivalent responses, especially when the child's sex differs from the sex the parents desire or when pregnancy intentions change after childbirth. 5he main reasons for these limitations include: (i) exclusion of women who have had induced abortions; (ii) lack of inclusion of partners' perspectives, despite their important role in pregnancy decisions; and (iii) failure to consider contraceptive use or non-use status at conception. 11,12These factors can lead to ambivalence, denial and confusion about pregnancy, and misreporting of partners' intentions, as a considerable portion of reported unintended pregnancies in low-and middle-income countries are wanted by the husband. 5,11,12o comprehensively measure pregnancy intention, multiple dimensions need to be considered, such as contraception use, feelings about pregnancy at conception and after birth, and partner agreement. 12The London Measure of Unplanned Pregnancy addresses these issues and can overcome the limitations of the DHS measure of pregnancy intention. 132][13][14] Furthermore, no previous investigation has been done into the discordance between the DHS measure of pregnancy intention and the London Measure of Unplanned Pregnancy or the factors contributing to this discordance.The aim of our study therefore was to estimate the prevalence of unintended pregnancy in Bangladesh using these two measures: the DHS timing-based estimate and the London Measure of Unplanned Pregnancy.We also sought to determine the degree of discordance between the prevalence estimates obtained from these two measures, and identify the factors that contribute to this discordance.

Study setting and sample
We used a cross-sectional survey design with a two-stage stratified random sampling method.First, using the lottery method, we randomly selected four districts in Bangladesh: Kurigram, Mymensingh, Pabna and Satkhira, from the 64 districts in total (Fig. 1).Then, we selected 20 hospitals, five from each district.We selected the one districtlevel hospital in each district.Then, in each district, we randomly chose one upazila (a district subunit) health complex from all upazila complexes; one union (smallest administrative unit) health complex from all union health complexes; and two private hospitals from all private hospitals.We obtained the list of hospitals providing maternal health-care services in the districts from the Ministry of Health and Family Welfare in Bangladesh.We used these hospitals as the sampling frame from which we selected eligible women.The eligibility criteria were women who had recently delivered a baby (either by caesarean section or vaginal delivery) and were visiting the selected hospitals for postnatal health-care services.Women who did not meet these criteria were excluded.Women were approached by the data collectors stationed at the hospitals.
We determined the sample size using the formula n = (z 2 × pq)/e 2 , where z = 1.96 at the 95% confidence level, p is the sample proportion, q = 1 -p and e is the margin of error.We estimated a 10% non-response rate (114 women). 15e increased the sample size required (n = 378) by three times to improve the precision of the study, and added the estimated number of non-responders for a final sample size of 1248 women.

Data collection
We collected data from 12 January to 4 February 2023, through face-to-face interviews administered by trained data collectors holding bachelor or postgraduate degrees in population science and anthropology.We devel-oped and tested a structured questionnaire which included the questions related to unintended pregnancy in both the DHS and the London Measure of Unplanned Pregnancy. 16We also incorporated other relevant questions from the Bangladesh DHS, such as respondents' sociodemographic background.The questionnaire underwent field-testing, with subsequent refinements made based on feedback received during pre-testing from the respondents.

Ethical considerations
The Human Research Ethics Committee of Jatiya Kabi Kazi Nazrul Islam University approved the final version of the questionnaire and the data collection method (approval number: JK-KNIU2023-07).
We obtained written or verbal informed consent from each respondent before data collection began.We informed the women of their right to withdraw at any time during the survey or to decline to answer any questions they felt uncomfortable with.Additionally, we assured the women of the confidentiality of their data which would not be shared with anyone in an identifiable form.

Outcome measure
Our primary outcome was discordant responses in pregnancy intention (yes, no) between the DHS measure and London Measure of Unplanned Pregnancy.Both approaches are globally validated, including in Bangladesh, with the London Measure of Unplanned Pregnancy being considered the most up-to-date and comprehensive measure. 13,16We generated the discordant response variable by comparing estimates of pregnancy intention from both measures.In the DHS measure, eligible women (those with at least one live birth within 5 years of the survey) are asked two questions.The first question asks whether the woman intended to become pregnant at conception, with response options of yes or no.A negative response leads to a follow-up question to determine whether not wanting to be pregnant was temporary (i.e.she wanted to be pregnant at a later time) or permanent (i.e.she did not want any (more) children).We categorized responses into intended pregnancy (positive response to the first question) and unintended pregnancy (negative response to the first

Research
question, and later or not at all in the second question; online repository). 17he London Measure of Unplanned Pregnancy records pregnancy intention through six questions in relation to the woman's last pregnancy: contraception use; attitude to timing of pregnancy; pregnancy intention; desire for a baby; discussion with partner about pregnancy; and actions taken to improve health in preparation for pregnancy (online repository). 17Based on responses and scores, this measure estimates unplanned pregnancy (score: 0-3), ambivalence to pregnancy (score: 4-9) and planned pregnancy (score: 10-12; online repository). 17We considered responses concordant if women reported similar pregnancy intentions in both measures (i.e.pregnancy rated intended and planned, or unintended and unplanned by both measures).Discordant responses were mismatches between the two measures (e.g.pregnancy rated intended by one measure and unintended by the other measure).

Explanatory variables
We first compiled a list of potential explanatory variables from a literature review in low-and middle-income countries, particularly in Bangladesh.
18,19 Next, we checked that all these variables were included in our survey.

Statistical analysis
We used descriptive statistics to present baseline characteristics and cross-tabulation to show discordant pregnancy intention.We used multivariable logistic regression analysis to explore factors associated with discordance and report odds ratios (ORs) with corresponding 95% confidence intervals (CIs).We estimated crude and adjusted associations and accounted for multicollinearity before modelling.We used Stata, version 15.2 (StataCorp.LP, College Station, United States of America) for all analyses.

Results
Of the 1248 women approached, 1204 agreed to participate in the survey, a response rate of 96.5%, which is consistent with other nationally representative health-related surveys in Bangladesh. 5 We excluded four respondents due to missing data on key variables (Fig. 1).Thus, our analysis included data from 1200 respondents, and their background characteristics are summarized in Table 1.Of the 1200 respondents, 962 (80.2%) were aged 20-34 years; 480 (40.0%) had a secondary education; and 828 (69.0%) were not formally employed.As regards partners, 434 (36.2%) had a higher education and 340 (28.3%) worked in business.The sex distribution of the last child was similar: 49.0% (588) males and 51.0% (612) females.Most of the women lived in rural areas (78.7%; 944).The prevalence of unplanned pregnancy was higher with the London Measure of Unplanned Pregnancy (31.0%; 373/1200) compared with the DHS measure (24.3%; 292/1200; online repository). 17Based on the London measure, 47.5% (570) of the respondents intended to become pregnant at conception, and 52.6% (631) reported that their pregnancy occurred at the right time.Additionally, 54.0% (648/1200) of pregnancies occurring with mutual agreement between spouses.In contrast, 29.0% (348) of women reported that they never discussed pregnancy with their partner.Before becoming pregnant 43.1% (517) reported that they had not taken any health actions, such as taking folic acid or seeking medical or health advice (Fig. 2).A total of 27.1% (325) of responses to pregnancy intention were discordant between the DHS measure and the London Measure of Unplanned Pregnancy (Table 2).
Several factors associated with discordant responses on pregnancy intention: older respondent age, female sex of the last child, having more than two children, belonging to the poor wealth quintiles, living in rural areas and living in Kurigram district were associated with a higher likelihood of discordant responses in the crude analysis.Secondary and tertiary education of the  3).

Discussion
We found a higher prevalence of unplanned pregnancy reported through the London Measure of Unplanned Pregnancy compared with the DHS measure.Additionally, more than a quarter of women provided discordant responses about pregnancy intention between the two measures.Predictors of discordant responses included older age; female sex of the last child; having more than two children; not being in formal employment; belonging to the poor wealth quintiles; living in a rural area; and living in the Kurigram district.These findings suggest the actual occurrence of unintended pregnancy in Bangladesh may exceed the current DHS estimate of 25.2%. 3Therefore, the burden on maternal and child health in other low-and middle-income countries related to unintended pregnancy may also be underestimated if based on DHS estimates.
The reported prevalence of unintended pregnancy measured through the DHS method in our study aligns with na-Fig. 2

Research
tional estimates in Bangladesh and other low-and middle-income countries. 1,3,18,19owever, using the more comprehensive London Measure of Unplanned Pregnancy showed a considerably higher prevalence of unplanned pregnancy, with 37.6% (451/1200) of pregnan-cies classified as either unplanned or ambivalent compared with the DHS estimate of 24.3%.The London Measure of Unplanned Pregnancy gave a more nuanced understanding of unintended pregnancy, with only half of pregnancies occurring with mutual agreement between spouses.Additionally, almost half of women reported not taking any health actions before pregnancy, indicating inadequate counselling on family planning and health check-ups before pregnancy.These findings cannot be easily validated due to limited data on pregnancy intention measured through the London Measure of Unplanned Pregnancy in Bangladesh and other lowand middle-income countries.Various factors could contribute to the higher estimate of unintended pregnancy using the London Measure of Unplanned Pregnancy.This measure collects feelings about a specific pregnancy from both partners, unlike the DHS measure, which focuses solely on women's feelings.Moreover, the London measure assesses pregnancy timing through multiple questions, while the DHS measure asks a single question about feelings at conception.Consequently, women can recall pregnancy details such as contraception use and failure, as well as partner feelings more accurately.Despite discrepancies in the results of the two measures, both approaches report high rates of unintended pregnancy.These high rates emphasize the need for comprehensive family planning services that address social norms and misconceptions around pregnancy, and provide counselling on family planning and preconception care. 11,12Neglecting these issues can lead to adverse maternal and child health outcomes.
Our findings highlight common mixed feelings or uncertainty about pregnancy intention among women in Bangladesh, with one in four responses on pregnancy intention being discordant.1][22] Additionally, the higher likelihood of discordance for women whose last child was female may reflect the persistent preference for male children in Bangladesh. 23Women may have wanted this child but reported it as unintended when it was a female child.The use of the two approaches to measure pregnancy intention may have led to these differences being captured, resulting in discordant responses.The preference for a son is particularly prevalent among women from lower wealth quintiles and rural areas, who rely heavily on agriculture and view Measuring unintended pregnancy, Bangladesh male children as primary workers and caregivers.][29] The high prevalence of discordance in rating pregnancy intention between the two measures suggests that many women have conflicting feelings about their pregnancies, which can adversely affect various aspects of their lives.For instance, women with contradictory feelings may delay or have limited access to maternal health-care services, as indicated by previous research. 3,6,7,30dditionally, women with unintended pregnancies or pregnancy ambivalence are more likely to engage in harmful behaviours during pregnancy, such as smoking, and have higher rates of depression and anxiety, often stemming from concerns about their career or education. 4,31These factors collectively contribute to increased risks of adverse maternal and child health outcomes, including the already high rates of maternal and child mortality observed in Bangladesh and other low-and middleincome countries. 5,8 strength of our study is the large sample, which exceeded the calculated size and enhanced the statistical power of the study.Additionally, using both the DHS measure and the London Measure of Unplanned Pregnancy offers a greater understanding of the extent of unintended pregnancy.However, our study has some limitations.The cross-sectional design of the study does not allow causal inferences.In addition, the inclusion criteria restricted the sample to women accessing postnatal health-care services at selected hospitals and hence excluded women who did not visit health-care facilities for such services, thus limiting the generalizability of the findings.Nevertheless, given the increasing accessibility of postnatal care, 5,7 the impact of this limitation is likely minimal.The use of self-reported interviews may also introduce reporting bias into the data, as some women may have been susceptible to providing socially desirable responses.The women, however, were assured of the anonymity of their responses before the interviews, which were carried out in a separate room with only the woman and the interviewer.During data collection, questions were asked carefully, with examples given for important ones.Therefore, any social desirability biases were likely to be random.Lastly, data on factors such as social norms about child sex preference were not collected because of the lack of relevant data in the survey, although they potentially influence discrepancies between the measures.
Our findings have important policy implications for Bangladesh.The high prevalence of unintended pregnancy, coupled with substantial discordance between the applied measures, underscores the significant burden of unintended pregnancy and its underreporting at a community level.5][6][7] Consequently, action is needed to implement comprehensive family planning services and encourage the uptake of contraception, with a focus on younger, economically disadvantaged and less educated women.These efforts should be integrated into existing family planning services and scaled up throughout Bangladesh.Surveys in low-and middle-income countries, including Bangladesh, should incorporate updated measures of unintended pregnancy, such as the London Measure of Unplanned Pregnancy, into their questionnaires (the DHS measure) to enable more accurate monitoring of the prevalence of unintended pregnancy.This inclusion would not incur additional expenses given the large number of variables already incorporated in the DHS surveys.

Resumen Comparación de dos métodos de encuesta para estimar los embarazos no planificados en Bangladesh
Objetivo Comparar la prevalencia del embarazo no deseado medida por la Encuesta Demográfica y de Salud (EDS) y la London Measure of Unplanned Pregnancy en Bangladesh, y explorar el grado de discordancia entre las medidas y los factores asociados con la discordancia.Métodos En 2023, se realizó una encuesta transversal en cuatro distritos de Bangladesh seleccionados al azar: Kurigram, Mymensingh, Pabna y Satkhira.Se seleccionaron al azar 20 hospitales, cinco de cada distrito.Se recopilaron datos de 1200 mujeres que habían dado a luz recientemente y acudían a los hospitales para recibir atención posnatal.Se entrevistó a las mujeres sobre su intención de embarazo en su último embarazo utilizando preguntas de la EDS y la London Measure of Unplanned Pregnancy, y se examinó la discordancia en sus respuestas.Se utilizó un análisis de regresión logística multivariable para identificar los factores asociados a las respuestas discordantes en la intención de embarazo declarada.

Fig. 1 .
Fig. 1.Flowchart of selection of women to interview for the comparison of survey methods for estimating unplanned pregnancy, Bangladesh, 2023